The Patient Information Release Form is a critical document used in Indonesian healthcare settings when there is a need to share patient medical information with authorized third parties. This form is essential for compliance with Indonesian regulations, particularly Law No. 36 of 2009 on Health and Law No. 27 of 2022 on Personal Data Protection. It serves multiple purposes, including facilitating continued care, insurance claims processing, legal proceedings, or research purposes. The document must be completed when a patient or their legal representative authorizes the release of medical records or health information to specified recipients. It includes detailed patient identification, specific consent parameters, and clear authorization statements, ensuring both legal compliance and protection of patient privacy rights.
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1. Patient Information: Essential identification details of the patient including full name, date of birth, medical record number, and contact information
2. Healthcare Provider Details: Information about the healthcare facility/provider releasing the information, including name, address, and contact details
3. Recipient Information: Details of the person or entity authorized to receive the medical information, including name, relationship to patient, organization (if applicable), and contact information
4. Information to be Released: Specific description of medical information authorized for release, including date ranges and types of records
5. Purpose of Release: Statement of the specific purpose for which the information is being released
6. Duration of Authorization: Specification of how long the authorization remains valid
7. Patient Rights Statement: Clear explanation of patient's rights regarding the release of information, including right to revoke authorization
8. Authorization Statement: Formal declaration of consent and understanding of the release terms
9. Signatures: Space for patient or legal representative signature, date, and witness signature if required
1. Specific Restrictions: Optional section for patients to specify any restrictions on what information can be shared, used when patient wants to limit scope of release
2. Electronic Release Authorization: Additional authorization for electronic transmission of records, included when digital transfer is possible
3. Legal Representative Authorization: Section for cases where someone other than the patient is authorizing the release, used when patient is minor or legally incapacitated
4. Prohibition of Redisclosure Notice: Additional notice prohibiting further sharing of information by recipient, used for particularly sensitive information
5. Payment Authorization: Section addressing any fees associated with records release, included when applicable under facility policy
1. Types of Medical Information Checklist: Detailed checklist of specific types of medical information that can be released (e.g., lab results, imaging reports, consultation notes)
2. Fee Schedule: If applicable, schedule of fees for different types of medical record releases as per facility policy
3. Sensitive Information Special Authorization: Separate authorization form for specially protected information (e.g., HIV status, mental health records, genetic information)
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